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ORIGINAL ARTICLE
Year : 2018  |  Volume : 45  |  Issue : 3  |  Page : 125-128

Effect of ondansetron in the prevention of spinal anesthesia-induced hypotension


1 Department of Anesthesiology, 4 Air Force Hospital Kalaikunda, West Midnapore, West Bengal, India
2 Department of Anaesthesiolgy, Military Hospital, Pithoragarh, Uttarakhand, India
3 Department of Anaesthesiology, 5 Air Force Hospital, Jorhat, Assam, India
4 Department of Anaesthesiology, Axon Hospitals, Bangalore, Karnataka, India
5 Department of Anaesthesiology, Command Hospital (Air Force), Bangalore, Karnataka, India

Date of Web Publication28-Jun-2019

Correspondence Address:
Dr. K Raghu
Department of Anesthesiology, 4 Air Force Hospital, Kalaikunda, West Midnapore, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_45_18

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  Abstract 


Background and Aims: Hypotension and bradycardia are the common side effects seen after spinal anesthesia. Multiple strategies are tested to prevent the postspinal anesthesia-induced hypotension. Recently, Ondansetron, a 5-HT3 antagonist commonly used as an antiemetic was found to be effective in preventing spinal anesthesia-induced hypotension. The aim of this study is to evaluate the effect of ondansetron in the prevention of spinal anesthesia-induced hypotension. Materials and Methods: A prospective, randomized, and double-blind study was conducted on 110 elderly patients, aged 50–70 years, of the American Society of Anesthesiologists Grade I or II category, scheduled for various surgeries under spinal anesthesia. The patients were randomly divided into two groups of 55 each to receive either ondansetron 8 mg (Group A) or saline (Group B) before spinal anesthesia. The primary outcome of the study was the incidence of hypotension (systolic blood pressure <100 mm Hg or fall >20% in the baseline values). Secondary outcomes, such as the requirement of ephedrine, the incidence of bradycardia, nausea, and vomiting were also recorded during the study. Results: Group A and Group B were comparable with respect to age, sex, height, and weight. Thirty-four patients in Group B (60.7%) and 22 patients in Group A developed hypotension (39.3%) (P = 0.0359) [Table 1]. The use of ephedrine was greater in Group B than that of Group A (mean 4.61 ± 1.80 vs. 3.45 ± 1.09, P = 0.0107). Thirteen patients in Group B and four patients in Group A had bradycardia (P = 0.0176). Nine patients in Group B and two patients in Group A had vomiting (P = 0.0261). Conclusion: We conclude that prophylactic administration of ondansetron is effective in reducing the incidence of spinal anesthesia-induced hypotension.

Keywords: Hypotension, ondansetron, spinal anesthesia


How to cite this article:
Raghu K, Kumar S, Rajaram G, Nikhil N, Damodar P. Effect of ondansetron in the prevention of spinal anesthesia-induced hypotension. J Sci Soc 2018;45:125-8

How to cite this URL:
Raghu K, Kumar S, Rajaram G, Nikhil N, Damodar P. Effect of ondansetron in the prevention of spinal anesthesia-induced hypotension. J Sci Soc [serial online] 2018 [cited 2019 Nov 17];45:125-8. Available from: http://www.jscisociety.com/text.asp?2018/45/3/125/261664




  Introduction Top


Spinal anesthesia is most commonly performed anesthetic technique worldwide. It is simple, fast performing, and reliable technique. Most common complication-associated with the spinal anesthesia is hypotension with an incidence of 25%–80%.[1]

The causes of hypotension after the administration of spinal anesthesia include sympathetic blockade-induced venodilation and Bezold–Jarisch reflex (BJR).[2] The venodilation leads to venous pooling of the blood and reduction in venous return. The BJR is a cardio-inhibitory reflex producing bradycardia, hypotension, and cardiovascular collapse. It occurs due to activation of the left ventricular mechanoreceptors from a sudden decrease in the left ventricular volume and is mediated by serotonin receptors.[3]

Multiple modalities have been tested in preventing and managing hypotension which includes positioning, lower-leg compression, preloading, co-loading of fluids, and use of vasopressors.[4] Recently, ondansetron a 5-HT3 antagonist used for the prevention and treatment of postoperative nausea and vomiting has been studied to attenuate spinal anesthesia-induced hypotension.[5]

The present study was conducted to evaluate the effect of ondansetron in the prevention of spinal anesthesia-induced hypotension.


  Materials and Methods Top


After obtaining the Institutional Ethics Committee approval, this was undertaken during the period from September 2017 to December 2017. Sample size estimation and selection of dose of ondansetron were based on the work of Shah SARA et al.[6] The study involved 110 patients from either gender aged 50–70 years, of the American Society of Anesthesiologists (ASA) Grade I or II, scheduled for various elective surgeries under spinal anesthesia. Exclusion criteria were patients with known hypersensitivity to ondansetron, cardiovascular, renal, hepatic diseases, and thyroid disease. All patients were assessed preoperatively counseled, and informed consent was obtained. Preoperative fasting of 6–8 h was advised.

Patients were randomly divided into two groups of 55 patients each using computer-generated random numbers. Group A received 8 mg ondansetron intravenously (IV) and Group B received 4 mL saline IV 10 min before spinal anesthesia. All the patients were preloaded with 500 mL of lactated Ringer's solution IV. Patients' peripheral oxygen saturation, blood pressure (systolic, diastolic, and mean arterial pressure), and electrocardiogram were monitored. Basal values were recorded.

The patients were placed in sitting position, and dural puncture was performed at L3–L4 interspace under full aseptic precautions. A total volume of 15 mg of 0.5% hyperbaric bupivacaine was injected intrathecally. Supine position was adopted after the administration of spinal anesthesia. Spinal anesthesia was administered by similarly trained anesthesiologists. Noninvasive blood pressure measurement was recorded immediately after subarachnoid block and repeated every 3 min in first 30 min followed by repeat measurements every 5 min till the end of surgery. Patients developing the primary endpoint of hypotension (systolic blood pressure <100 mm Hg or fall >20% in baseline values) were treated with injection ephedrine 6 mg IV, and those developing bradycardia (heart rate <50 bpm) was treated with injection atropine 0.6 mg IV. Patients were also assessed for secondary endpoints such as feeling of nausea, dizziness, and observed for vomiting.

The mean and standard deviation were used for age and weight, and independent t-test was used to compare if the difference between the two groups was significant. Frequency of bradycardia, hypotension, and use of ephedrine, and incidence of nausea/vomiting were expressed in percentage, and compared using Chi-square test. A value of P < 0.05 was taken as statistically significant.


  Results Top


A total of 110 patients aged 50–70 years, of ASA Grade I or II, of either gender scheduled for various surgeries under spinal anesthesia were enrolled for this study [Table 2]. Patients were divided into two groups [Figure 1]. Group A received 8 mg ondansetron and Group B received saline 10 min before spinal anesthesia. Fifty-five patients were included in Group A, and 55 patients in Group B. There was no statistical difference between the two groups in age, weight, and height. Incidences of hypotension and ephedrine requirement following spinal anesthesia were noted. Fifty-six patients out of 110 developed hypotension (50.9%), of whom 34 were in the Group B (60.7%) and 22 patients were in Group A (39.3%). The incidence of hypotension was statistically significant between the two groups (P = 0.0359) [Table 1]. The use of ephedrine was greater in Group B than that of Group A (mean 4.61 ± 1.80 mg vs. 3.45 ± 1.09 mg, P = 0.0107). Thirteen patients in Group B and four patients in Group A had bradycardia (P = 0.0176). Nine patients in Group B and two patients in Group A had vomiting (P = 0.0261). Six patients in Group B and two patients in Group A had nausea feeling (P = 0.1419).
Table 2: Patient parameters

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Figure 1: Consort flow chart

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Table 1: Hemodynamic data

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  Discussion Top


Spinal anesthesia offers many advantages in elderly patient which includes postoperative pain relief, minimizes polypharmacy, and decrease in the incidence of venous thrombosis. However, it is also associated with the own share of side effects and complications. Hypotension and bradycardia are most commonly seen side effects of spinal anesthesia with a potential to lead to significant complications. The incidence of spinal anesthesia-induced hypotension is between 25% and 80% of cases.[1] The causes of hypotension after the administration of the spinal anesthesia are numerous, but the main causes are sympathetic blockade with a parasympathetic overdrive and the BJR.[7],[8] BJR is a cardio-inhibitory reflex producing bradycardia, hypotension, and cardiovascular collapse, which occurs due to activation of the left ventricular mechanoreceptors from sudden decrease in the left ventricular volume and is mediated by serotonin receptors.[9]

Many studies are done to identify the prevention and treatment strategies for the spinal anesthesia-induced hypotension and bradycardia. These strategies include positioning, lower-leg compression, intravascular preloading and co-loading of crystalloids and colloids, and administration of pharmacologic vasopressors.[4],[10] Recently, ondansetron has been studied in spinal anesthesia-induced hypotension and bradycardia.[5] Ondansetron, a 5-HT3 antagonist, is widely used for the prevention and treatment of postoperative nausea and vomiting. Due to its antagonistic effect on the 5-HT3 receptor, it may be considered for attenuating spinal anesthesia-induced hypotension and bradycardia. We decided to conduct this study to assess the effects of 5-HT3 antagonist to prevent hypotension after the administration of spinal anesthesia in the elderly. Intrathecal dose selection and power of study are based on previous studies.[6]

From our study, we found out that the overall incidence of hypotension was % (50.9%). The incidence of hypotension was more inthe saline group (60.7%) when compared to ondansetron group (39.3%). Ephedrine requirement in saline group was higher than the ondansetron group. The incidence of bradycardia was also higher in saline group when compared to ondansetron group.

Shah SARA et al.,[6] conducted study to find out the effectiveness of prophylactic administration of ondansetron for the prevention of spinal anesthesia-induced hypotension in elderly patients. They included 100 patients and divided into two groups of 50 each. Each patient was preloaded with Ringer's lactate solution in a dose of 10 mL/kg. Patients of Group A received 8 mg of ondansetron IV 5 min before the administration of spinal anesthesia, whereas patients of Group B were injected normal saline IV. They found that hypotension was present in 23 (46%) patients in Group A, whereas it was present in 34 (68%) patients in Group B (P = 0.026). Bradycardia was recorded in 3 (06%) versus 11 (22%) patients in Group A and B, respectively (P = 0.021). They concluded that intravenous administration of 8 mg of ondansetron 5 min before subarachnoid block is effective in decreasing frequency of hypotension and bradycardia in elderly patients. Results of their study are comparable to ours in terms of incidence of hypotension and requirement of ephedrine between groups.

Owczuk et al.[11] conducted study to assess the effect of ondansetron in attenuating spinal anesthesia-induced hypotension. They included 53 patients in their study, who were aged above 70 years. Twenty-six patients received the ondansetron 8 mg IV, and 27 patients received 4 mL of saline. Hypotension was observed in 13 (48.1%) patients in the placebo group and 10 (38.5%) in ondansetron group (P = 0.477) and difference was not statistically significant; however, they found out that fall in systolic and mean arterial pressure was minimal in the ondansetron group when compared to the saline group. They also found out that 12 patients in saline group and five patients in ondansetron group required ephedrine (P = 0.049) and it was statistically significant. They concluded that ondansetron given IV attenuates the fall of systolic and mean blood pressure. Results of their study demonstrated a lower incidence of hypotension and ephedrine requirement in the ondansetron group when compared to the saline group was comparable to our findings.

Marashi et al.[12] conducted a study to compare the two different doses of intravenous ondensetron with placebo on attenuation of spinal anesthesia-induced hypotension. They included 210 patients and divided into three groups of 70 each. The first group received saline, the second group received 6 mg of ondansetron, and the third group received 12 mg ondansetron. They found out that 12 patients in the control group had hypotension and none of the patients in ondansetron group experienced hypotension (P = 0.04). Results of this study are comparable to ours in terms of higher incidences of hypotension in the saline group when compared to ondansetron group.


  Conclusion Top


We conclude that prophylactic use of 8 mg ondansetron IV is effective in reducing the development of spinal anesthesia-induced hypotension, bradycardia, and vomiting and hence reducing the intravenous ephedrine requirements.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yap JC, Critchley LA, Yu SC, Calcroft RM, Derrick JL. A comparison of three fluid-vasopressor regimens used to prevent hypotension during subarachnoid anaesthesia in the elderly. Anaesth Intensive Care 1998;26:497-502.  Back to cited text no. 1
    
2.
Liu SS, McDonald SB. Current issues in spinal anesthesia. Anesthesiology 2001;94:888-906.  Back to cited text no. 2
    
3.
Mark AL. The Bezold-Jarisch reflex revisited: Clinical implications of inhibitory reflexes originating in the heart. J Am Coll Cardiol 1983;1:90-102.  Back to cited text no. 3
    
4.
Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW. Techniques for preventing hypotension during spinal anaesthesia for caesarean section. Cochrane Database Syst Rev 2006;(4):Cd002251.  Back to cited text no. 4
    
5.
Sahoo T, SenDasgupta C, Goswami A, Hazra A. Reduction in spinal-induced hypotension with ondansetron in parturients undergoing caesarean section: A double-blind randomised, placebo-controlled study. Int J Obstet Anesth 2012;21:24-8.  Back to cited text no. 5
    
6.
Shah SA, Naqvi SS, Abbas MA. Efficacy of prophylactic intravenous administration of ondansetron for prevention of spinal anesthesia induced hypotension in elderly patients. Anaesth Pain Intensive Care 2016;20:17-20.  Back to cited text no. 6
    
7.
Tubog TD, Kane TD, Pugh M. The effects of ondansetron on attenuating spinal anaesthesia induced hypotension and bradycardia in a obstetric and non-obstetric subjects: A systemic review and meta-analysis. AANA J 2017;85:113-22.  Back to cited text no. 7
    
8.
Campagna JA, Carter C. Clinical relevance of the Bezold-Jarisch reflex. Anesthesiology 2003;98:1250-60.  Back to cited text no. 8
    
9.
Martinek RM. Witnessed asystole during spinal anesthesia treated with atropine and ondansetron: A case report. Can J Anaesth 2004;51:226-30.  Back to cited text no. 9
    
10.
Veeser M, Hofmann T, Roth R, Klöhr S, Rossaint R, Heesen M, et al. Vasopressors for the management of hypotension after spinal anesthesia for elective caesarean section. Systematic review and cumulative meta-analysis. Acta Anaesthesiol Scand 2012;56:810-6.  Back to cited text no. 10
    
11.
Owczuk R, Wenski W, Twardowski P, Dylczyk-Sommer A, Sawicka W, Wujtewicz MA, et al. Ondansetron attenuates the decrease in blood pressure due to spinal anesthesia in the elderly: A double blind, placebo-controlled study. Minerva Anestesiol 2015;81:598-607.  Back to cited text no. 11
    
12.
Marashi SM, Soltani-Omid S, Soltani Mohammadi S, Aghajani Y, Movafegh A. Comparing two different doses of intravenous ondansetron with placebo on attenuation of spinal-induced hypotension and shivering. Anesth Pain Med 2014;4:e12055.  Back to cited text no. 12
    


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